| IndigestionDefinition - Indigestion is a nonspecific term that encompasses a variety of upper abdominal complaints that are often related to food intake.
- The meaning of the term varies but often includes:
- Heartburn
- Regurgitation
- Dyspepsia (upper abdominal discomfort or pain)
- The most common causes of indigestion are:
- Gastroesophageal reflux disease (GERD)
- Functional dyspepsia, defined as:
- ≥3 months of bothersome postprandial fullness, early satiety, epigastric pain, or epigastric burning
- Symptom onset at least 6 months before diagnosis
- Absence of identifiable organic cause
- Intestinal lactase deficiency
 Epidemiology - Incidence/prevalence
- Heartburn is reported once monthly by 40% of Americans and daily by 7%–10%.
- Nearly 25% of the population has abdominal discomfort at least 6 times yearly, but only 10%–20% of affected individuals consult physicians.
- Intestinal lactase deficiency occurs in 15% of Caucasians of northern European descent but is more common in African Americans and Asians.
- Clinical manifestations may increase with age because lactase activity declines with age.
Mechanism - Visceral pain
- Typically dull and aching; associated with feelings of fullness or pressure
- Mediated by visceral afferent nerves
- Location corresponds to segmental level of neural innervation of the affected organ.
- Inflammation lowers threshold for tolerance of visceral pain.
- Heartburn
- Substernal/high epigastric sensation of burning or warmth
- May result from:
- Abnormal motor activity of esophagus
- Sensitivity of esophageal mucosa to bile or acid
- Esophageal mucosal inflammation
- Abdominal gaseousness or bloating
- Fermentive action of intestinal bacteria and the ingestion of certain foods can lead to excessive gas formation.
- Excessive quantities of intestinal gas lead to visceral pain.
- Motility disturbances can cause normal amounts of gas to be perceived as excessive.
Symptoms & Signs - Because indigestion is nonspecific, it is important to ascertain patient’s description of symptoms, including:
- Character of symptoms
- Timing
- Relationship to meals
- Alleviating/exacerbating factors
- Symptoms
- Heartburn
- Warmth or burning in the substernal/upper epigastric area
- Chest pain may mimic angina
- May be worse after certain foods (e.g., citrus, alcoholic beverages, fatty foods)
- Often alleviated by antacids
- Salty, sour, or bitter taste in the mouth that comes from regurgitation of gastric contents and bile (often accompanies heartburn)
- Epigastric gnawing
- Fullness or pain that is aggravated by eating
- Nausea
- Eructation (belching)
- Dry cough
- Early satiety
- Physical examination
- Usually normal in individuals with GERD and functional dyspepsia
Differential Diagnosis - Discrimination between functional and serious organic causes ("alarm factors")
- Odynophagia suggests esophageal infection.
- Dysphagia promotes concern about a benign or malignant esophageal blockage.
- Other features that raise alarm include:
- Unexplained weight loss
- Recurrent vomiting
- Occult or gross GI bleeding
- Jaundice
- A palpable mass or adenopathy
- A history of previous upper GI malignancy or peptic ulcer disease
- Indigestion can be a symptom of:
- Functional (non-ulcer) dyspepsia (60% of patients)
- Characterized by epigastric pain or abdominal distention
- Sometimes accompanied by heartburn, bloating, belching, nausea or vomiting
- GERD
- Heartburn, bitter or sour taste of regurgitated fluid, worsening of symptoms with lying supine, and improvement with antacids are typical features.
- Pharyngeal erythema; cough and wheezing may be present
- Poor dentition may occur with prolonged acid regurgitation.
- Alkaline reflux esophagitis produces GERD-like symptoms in patients who have had surgery for peptic ulcer disease.
- Peptic ulcer disease
- Characterized by burning epigastric pain 1–3 hours after meals, relieved by food or antacids
- Gastritis
- Variable presentation
- Acute gastritis characterized by acute onset of epigastric pain, nausea, and vomiting
- Malignancies
- Intestinal lactase deficiency
- Produces gas, bloating, discomfort, and diarrhea after lactose ingestion
- Other carbohydrate-intolerance syndromes (e.g., fructose, sorbitol) produce similar symptoms.
- Irritable bowel syndrome
- May produce diffuse abdominal discomfort and bloating
- Biliary colic
- Most patients with true biliary colic report discrete episodes of right upper quadrant or epigastric pain rather than chronic burning discomfort, nausea, and bloating.
- Less common causes
- Pancreatic disease (chronic pancreatitis and malignancy)
- Hepatocellular carcinoma
- Celiac sprue
- Ménétrier’s disease
- Infiltrative diseases (sarcoidosis and eosinophilic gastroenteritis)
- Mesenteric ischemia
- Thyroid and parathyroid disease
- Abdominal wall strain
Diagnostic Approach - Because indigestion is prevalent and most cases result from GERD or functional dyspepsia, only limited and directed testing of selected individuals is recommended.
- GERD
- Once alarm factors are excluded, patients with typical GERD do not need further evaluation and are treated empirically.
- Endoscopy is recommended for patients with heartburn ≥5 years in duration, especially in patients ≥50 years old.
- Ambulatory esophageal pH testing is considered for drug-refractory symptoms and atypical symptoms.
- Unexplained dyspepsia
- Upper endoscopy is indicated for patients whose risk of malignancy and ulcer is higher.
- Are >55 years old
- Have alarm factors
- Are taking NSAIDs
- "Test and treat" approach is indicated for younger patients without alarm factors who are not taking NSAIDs.
- Determine Helicobacter pylori status by urea breath testing, stool antigen measurement, or blood serology testing.
- If positive, treat for H. pylori.
- If negative, treat with acid suppressive regimen.
- In regions with low H. pylori prevalence (< 10%), starting with a 4-week trial of a potent acid-suppressing medication such as a proton pump inhibitor is recommended.
- If this fails, then initiate test and treat approach described above.
- Reserve endoscopy for those who fail to respond to treatment.
Laboratory Tests - Determination of H. pylori status
- Further testing if specific etiology is suspected
- Complete blood count: if bleeding reported
- Thyroid chemistries or calcium levels: if metabolic causes suspected
- Liver function tests, amylase: for suspected pancreaticobiliary causes
Imaging - Barium swallow or complete upper GI contrast study
- Sometimes used to evaluate for esophageal stricture, ulcer
- Gastric emptying scintigraphy
- Considered for patients with dysmotility-like dyspepsia when drug treatment fails
- Abdominal ultrasound or CT
- Used if symptoms or initial workup suggests hepatobiliary cause
Diagnostic Procedures - Upper endoscopy
- Performed as initial diagnostic test in patients with unexplained dyspepsia who:
- Are ≥45 years old
- Have alarm factors
- Are taking NSAIDs
- For those with chronic GERD, endoscopy is recommended to screen for Barrett’s metaplasia.
- Ambulatory esophageal pH testing
- Considered for drug-refractory symptoms and atypical symptoms such as unexplained chest pain
- Bernstein test
- Blinded perfusion of saline then acid into the esophagus via nasogastric tube or manometric assembly
- Can delineate whether unexplained chest discomfort results from acid reflux
- Esophageal manometry
- Most commonly ordered when surgical treatment of GERD is considered
- A low lower esophageal sphincter (LES) pressure may predict failure with drug therapy and identify patients who may require surgery.
- Manometry with provocative testing may clarify the diagnosis in patients with atypical symptoms.
- Hydrogen breath testing after lactose ingestion
- Rarely performed for suspected lactase deficiency
Treatment Approach - Treatment depends on the underlying cause of indigestion.
- GERD
- Discontinuation of drugs that exacerbate acid reflux
- Dietary changes
- Elevation of the head of the bed
- Acid-suppressing medications
- See Gastroesophageal Reflux Disease for details.
- Functional dyspepsia
- Reassurance and patient education
- Clearing H. pylori infection
- Acid-suppressing medications
- Prokinetic medications
- Lactase deficiency
- Milk product consumption should be reduced or eliminated from the diet.
- Lactase enzymes can be added or taken with dairy products.
- Peptic ulcer disease
Specific Treatments Gastroesophageal reflux disease Functional dyspepsia- Reassurance and patient education
- Gas and bloating
- Treating H. pylori infection (see below)
- Acid-suppressing medications
- Meta-analysis of 8 controlled trials calculated a risk ratio of 0.86 (95% confidence interval 0.78–0.95) favoring proton pump inhibitor therapy over placebo.
- The benefits of less potent acid-reducing therapies such as H2 antagonists are unproved.
- See Gastroesophageal Reflux Disease: Specific Treatments for doses.
- Prokinetic drugs (see below)
- Low-dose tricyclic antidepressants
- For patients refractory to acid suppressants or prokinetic drugs
- Mechanism of action is unknown but may involve blunting of visceral pain processing in the brain.
- Therapies that modify gut flora, including antibiotics and probiotic preparations containing active bacterial cultures, are useful for cases of bacterial overgrowth and functional lower GI disorders.
- Utility in functional dyspepsia is unproved.
- Psychological treatments may be offered for refractory functional dyspepsia, but no convincing data suggest efficacy.
H. pylori eradication - H. pylori eradication is indicated for peptic ulcer disease and gastric mucosa–associated lymphoid tissue lymphoma.
- The utility of eradication therapy in functional dyspepsia is less well established, but < 15% of cases relate to this infection.
- Meta-analysis of 13 controlled trials calculated a risk ratio of 0.91 (95% confidence interval 0.87–0.96) favoring H. pylori eradication therapy over placebo.
- Several drug combinations show efficacy; most include 10–14 days of a proton pump inhibitor or bismuth subsalicylate in concert with 2 antibiotics. Examples include:
Prokinetic medications - GERD
- Motor stimulants such as metoclopramide and erythromycin have limited utility in GERD.
- The γ-aminobutyric acid B agonist baclofen reduces esophageal acid exposure by inhibiting transient LES relaxations; the clinical role of the drug is being studied.
- Functional dyspepsia
- Several studies have evaluated the effectiveness of motor-stimulating drugs in functional dyspepsia.
- Convincing evidence of their benefits has not been found.
- Some clinicians suggest that patients with symptoms resembling postprandial distress may respond preferentially to prokinetic drugs.
- Metoclopramide has some efficacy in functional dyspepsia.
- May be given instead of acid suppressants as initial empirical therapy of young patients without alarm factors and without H. pylori infection.
- These agents should not be used long term as there is a risk of serious side effects with long-term use.
- Dysmotility-like dyspepsia
- Patients may respond preferentially to motor-stimulating drugs.
Monitoring - Patients with ongoing symptoms after empiric treatment should undergo further diagnostic evaluation.
- Patients with chronic GERD should undergo endoscopy as they are at higher risk for Barrett’s esophagus; subsequent periodicity of repeat endoscopy depends on initial findings.
Complications - GERD
- Reflux esophagitis
- Esophageal ulcers and strictures
- Occur in 5% of patients with GERD
- Barrett’s esophagus
- 8–20% of those with GERD develop glandular epithelial cell metaplasia, or Barrett’s esophagus.
- Can progress to adenocarcinoma (See Gastroesophageal Reflux Disease.)
- Pulmonary aspiration causing
- Aspiration pneumonia
- Pulmonary fibrosis
- Chronic asthma
- Other extraesophageal manifestations
- Laryngitis
- Chronic cough
- Dental caries
- Halitosis
- Hiccups
- Laryngeal and tracheal stenosis
Prognosis - Prognosis depends on the underlying cause of indigestion.
- For patients without alarm factors, the prognosis is generally good.
Prevention - Dietary modifications based on the foods that trigger symptoms may be helpful.
ICD-9-CM - 536.8 Dyspepsia and other specified disorders of function of stomach (includes indigestion)
See Also Internet Sites General Bibliography - Abell TL et al: Treatment of gastroparesis: a multidisciplinary clinical review. Neurogastroenterol Motil 18:263, 2006 [PMID:16553582]
- DeVault KR, Castell DO, American College of Gastroenterology: Updated guidelines for the diagnosis and treatment of gastroesophageal reflux disease. Am J Gastroenterol 100:190, 2005 [PMID:15654800]
- DiBaise JK, Brand RE, Quigley EM: Endoluminal delivery of radiofrequency energy to the gastroesophageal junction in uncomplicated GERD: efficacy and potential mechanism of action. Am J Gastroenterol 97:833, 2002 [PMID:12003416]
- Galmiche JP et al: Functional esophageal disorders. Gastroenterology 130:1459, 2006 [PMID:16678559]
- Kahrilas PJ, Lee TJ: Pathophysiology of gastroesophageal reflux disease. Thorac Surg Clin 15:323, 2005 [PMID:16104123]
- McColl KE et al: Randomised trial of endoscopy with testing for Helicobacter pylori compared with non-invasive H pylori testing alone in the management of dyspepsia. BMJ 324:999, 2002 [PMID:11976239]
- Moayyedi P et al: Helicobacter pylori eradication does not exacerbate reflux symptoms in gastroesophageal reflux disease. Gastroenterology 121:1120, 2001 [PMID:11677204]
- Rabeneck L et al: A double blind, randomized, placebo-controlled trial of proton pump inhibitor therapy in patients with uninvestigated dyspepsia. Am J Gastroenterol 97:3045, 2002 [PMID:12492188]
- Sampliner RE, Practice Parameters Committee of the American College of Gastroenterology: Updated guidelines for the diagnosis, surveillance, and therapy of Barrett's esophagus. Am J Gastroenterol 97:1888, 2002 [PMID:12190150]
- Tack J et al: Clinical and pathophysiological characteristics of acute-onset functional dyspepsia. Gastroenterology 122:1738, 2002 [PMID:12055579]
- Tack J et al: Functional gastroduodenal disorders. Gastroenterology 130:1466, 2006 [PMID:16678560]
- Talley NJ, Vakil NB, Moayyedi P: American gastroenterological association technical review on the evaluation of dyspepsia. Gastroenterology 129:1756, 2005 [PMID:16285971]
- Talley NJ, Vakil N, Practice Parameters Committee of the American College of Gastroenterology: Guidelines for the management of dyspepsia. Am J Gastroenterol 100:2324, 2005 [PMID:16181387]
- Talley NJ: Dyspepsia: management guidelines for the millennium. Gut 50 Suppl 4:iv72, 2002 [PMID:11953354]
- This topic is based on Harrison’s Principles of Internal Medicine, 17th edition, chapter 39, Nausea, Vomiting, and Indigestion by WL Hasler.
PEARLS - Patients with lactose intolerance may develop osteopenia and osteoporosis due to inadequate calcium intake.
- Remember the advice of Moses Maimonides: No illness that can be treated by diet should be treated by any other means.
- Indigestion is a common somatic complaint of individuals experiencing stress, anxiety, or other mental illness.
- Be alert to the fact that the development of indigestion and loss of appetite is a common manifestation of caregiver burnout, a condition that affects individuals who carry a major burden for the care of a sick relative or spouse.
- A vast array of herbal and alternative therapies is used to treat indigestion. Pay attention to the development of alarm factors that demand further investigation and be sure to take a careful medication history as some complementary remedies may have unexpected side effects.
- In patients with GERD that is refractory to medical therapy, the most useful study is 24-hour simultaneous monitoring of gastric and esophageal pH while on antisecretory medication.
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